2.0 Analysis 2.1 Decision to Sail On the morning of the occurrence, the master twice made conscious decisions to transit between Little Tub Harbour and Flowerpot Island. The first decision was to transit to Flowerpot Island in the face of the small craft warning and the thunderstorm advisory issued by Environment Canada. On arrival at Flowerpot Island, the master had an opportunity to remain alongside at Beachy Cove until the sea conditions improved. While he had just made the crossing in near gale-force winds and fielded concerns about the weather conditions, the master elected to proceed with the return voyage. The master's decisions to sail to and from Flowerpot Island were shaped by his perception of the risks associated with the transit. 2.1.1 Perception of Risk The master was aware that a small craft warning and a thunderstorm advisory were in effect but he believed that the crossings could be made. The master's perception of risk was tempered by his previous exposure to similar and worse conditions in over twenty years of operating this vessel in this area. Upon departing Little Tub Harbour, the TRUE NORTH II was in the lee of the Bruce Peninsula; the waves there were smaller than on the more exposed, windward side of Flowerpot Island, where confused seas prevailed due to the shoreline effect. Also, while some operators decided not to sail to Flowerpot Island that day, the master knew that the shallow draught of the TRUE NORTH II allowed him to enter Beachy Cove where other, larger vessels could not proceed. The vessel's inspection certificate did not clearly state the operational limitations on the vessel, as it allowed the master to proceed in fine clear weather only at master's discretion. The first part of the limitation is open to interpretation but the second part, at master's discretion, allowed the master to base his decision to sail upon his own judgement of the risk associated with the weather. The master understood neither the serious shortcomings of the vessel's condition (with regard to watertight integrity) nor the effect that the southwest wind would have on his vessel; he overestimated the ability of his vessel to withstand the head-on encounter with the waves, and underestimated the result of shipping water. 2.1.2 Pressure to Sail While specific arrangements had been made to pick up the group at 1000 the following day, no contingency plans were discussed and no alternative plans or telephone communications were made on the morning of June 16 to cancel or postpone the trip due to poor weather. As a result, the master would have felt a personal commitment to proceed to Flowerpot Island to rendezvous with the school group. 2.2 Master Certification and Training The master's certification met the minimum requirements of the Crewing Regulations to operate the TRUE NORTH II in the trade in which she was engaged. From 1981 to 1997 the master held a CSC certificate, renewable annually at the beginning of the navigation season. In 1998 he was issued, without examination, a CL certificate on the basis of holding a CSC certificate. The new CL certificate simply reflected the criteria previously stated on the CSC certificate. The CL certificate is a certificate of competency which has to be renewed every five years. Even though every applicant for a CL certificate must pass an oral, practical and written examination, the TCMS examiner may renew the CL certificate without examination if he or she is satisfied that the holder has continued to operate in the same capacity for the last five years. When examining a new applicant for a CL certificate, the TCMS examiner determines whether the person is competent to operate a specific vessel in a designated area where certain constraints, such as weather, can be expected. To assess a candidate, the TCMS examiner is guided by the general requirements for the CL certificate. The examination is based on a syllabus that encompasses various aspects of vessel operation such as navigation safety, engineering knowledge, general seamanship, ship management, and chart work and pilotage. The examination and certification practices for the CSC or CL certificates are left to the discretion of the local TCMS examiner. The local examiner determines which part of the syllabus is appropriate to the operation, type of craft and equipment carried on board and conducts oral examinations which, in rare cases, may be supplemented by written papers. The knowledge required to understand local weather forecasts or to recognize shortcomings with a vessel's watertight integrity is not part of the syllabus for this certificate. Since 1993, an instruction to TCMS examiners covered the preparation and evaluation of oral examinations, the latest version of which was issued on 30 June 2000. The instruction states that special care should be taken to document responses that are unsatisfactory or where the candidate is borderline. The master was last given an oral exam in 1983. As there is no documentation as to how the examination was conducted, it is not possible to determine how the TCMS examiner assessed the master's competence in operating the TRUE NORTH II. In April 2000 the master took MED Level 2 training at Georgian College. The master continued to stow the lifejackets and the liferaft in the same manner as before and he did not institute a passenger safety briefing or conduct an emergency drill or exercise. 2.3 Crewing Level In December 1978, at the request of the previous owner, the vessel was re-measured by TC and a gross tonnage of 5.67 was assigned. The Board of Steamship Inspection then required, among other things, that the vessel carry two crew members for the safety of passengers. In 1979 the present owner was hired as a second crew member. Since 1981, when the vessel changed ownership, the new owner operated the vessel single-handedly. The TCMS inspectors did not ensure that the operator had engaged a second crew member to meet the requirement for a crew of two, prior to the issue, each year, of the SIC 16. The certificates made no reference to this requirement. This meant that an additional crew member trained in emergency and survival procedures was not available to assist the master during the sinking. An additional crew member, if properly trained, might have been able to assist in the handing out of lifejackets to passengers or in the launching of the inflatable liferaft located on the top of the superstructure. 2.4 Meaning of Fine Clear Weather only at Master's Discretion Passenger vessel inspection certificates issued by TCMS contain limitations with regard to voyage and weather. The intent of the limitations is to reduce risks to passengers on small vessels. The master had worked on this vessel in the area of the marine park since 1980. During this period he had experienced a range of weather and sea conditions. When he sailed the morning of June 16, he had listened to the weather broadcast and was aware of the weather, the small craft warning, and the thunderstorm advisory. The Ship Inspection Certificate restricted the vessel to sail in fine clear weather only at master's discretion. This notation is imprecise and does not define any physical wind and sea limitations useful for small vessel operators. The master considered that the operating restriction did not prevent him from proceeding to Flowerpot Island, nor from returning to Tobermory, in the prevailing weather and sea conditions. The Board of Steamship Inspection exemption permitted the vessel to sail in fine and clear weather only . . . . The Ship Inspection certificates were different, in that the vessel was permitted to sail in fine clear weather only at master's discretion. This element of discretion, which made the limitation less restrictive, was not contained in the original exemption. Definitions of in fine weather vary from one official publication to another. For example, Transport Canada's Recommended Code of Nautical Procedures and Practices (TP 1018), states that the officer of the watch should pay particular attention to the state of the weather and sea. This would suggest that weather is distinct from seas. The Home-Trade, Inland and Minor Waters Voyages Regulations also refer to voyages in fine weather, but without any definitions. The Interim Guidelines to the Interim Passenger Vessel Compliance Program also introduce voyage limitations and provide an expanded definition of voyages in fair weather only as fine, clear settled weather, with a sea state such as to cause only moderate rolling and/or pitching. The lack of a clear definition of in fine weather, and industry-wide understanding of its derivations, leaves the interpretation of the limitation up to individual masters and would be dependent on the size and design of their vessels. Some may take it to mean atmospheric and sea conditions, while others may take it to mean atmospheric conditions only. The use of the qualifier at master's discretion, which is often appended to the limitation, further calls into question the effectiveness of such a limitation. 2.5 Vessel Condition After Recovery Inspection of the recovered vessel showed that the shell plating and underwater fittings of the TRUE NORTH II were intact and effective in preventing the entry of flood water into the hull. However, the lack of watertight integrity of the main deck--due to the non-watertight condition of three access hatches, the main engine casing and ventilators--made the vessel highly vulnerable to downflooding in the event of water being shipped on board. Since the non-watertight openings were distributed throughout the length of the main deck and water downflooded through all of them, transverse watertight subdivision would not have provided protection against progressive flooding. In order to ensure adequate drainage of shipped water from exposed decks, the HCR require that vessels of all classes and tonnage be fitted with bulwark freeing ports as set out in the Load Line Rules. The actual freeing port area in the steel bulwarks on each side of the TRUE NORTH II was approximately 10 percent of the minimum requirement and, consequently, the rate at which shipped water could be cleared from the main deck was severely limited. That two of the four freeing ports with which the vessel was originally fitted were welded shut exacerbated the situation and led to the rapid accumulation of shipped water on deck and the subsequent downflooding of the underdeck compartment. The total effective area of the foredeck scuppers was equivalent to one 75 mm internal diameter pipe, and any increase in their efficiency due to the venturi (suction) effect of their external cowlings was only effective when they were fully immersed and the vessel was making significant forward progress. The water which was shipped over the bow and retained up to the level of the bulwark top rail amounted to some 1.3 tonnes. While this was draining through the scuppers and also flowing aft through the gap at the bottom of the bridge front door, the vessel remained trimmed by the bow. While so trimmed, the vessel was vulnerable to shipping more water over the bow and the bridge front was also exposed to further wave impacts. The wood-framed plywood superstructure was open on each side and at its after end, and was intended to provide some shelter from the sun, wind and inclement weather for passengers carried on the main deck. Because of its greater exposure to headwinds and bow spray, the bridge front was constructed with two layers of 12 mm thick plywood, while the remainder of the superstructure sides and the bridge front door were made from a single layer. While the bridge front structure was more robust than the remainder of the superstructure, the forward facing window and its frame was of less than fully weathertight construction and unsuitable to withstand the loads and impacts imposed by solid water. The single layer plywood construction and insubstantial securing devices and hinges of the bridge front door made it more vulnerable in the event of waves being shipped over the bow. The deteriorated condition of the bridge front and its wooden framing in way of the door and window frames and the reduced support in the lower area of the door were such that, in the event, the bridge front door and window were unable to withstand the forces imposed on them. The effective height__in way of the ship side guard chains across the transom and at the after end of the open superstructure__of 0.670 m was less than the 1.0 m minimum safety requirement. While this condition was not a factor in the vessel's sinking, it presented an unnecessary risk to passengers, especially on a vessel that routinely carries groups of children. 2.6 Vessel Inspection The operators of small passenger vessels may not always be conversant with all safety requirements and may rely on the annual inspection as a means of ensuring compliance with all of the various government regulatory requirements. From the time of her entry into service as a passenger vessel in 1972, until 2000, the TRUE NORTH II was inspected annually in accordance with the Hull Inspection Regulations to ensure compliance with HCR, LSE and other regulatory requirements. Throughout this 28-year period various modifications and additions to the structure, propelling machinery and safety equipment were carried out, which were inspected and accepted by the (then) CSI, and latterly by TCMS. The details of past annual inspections recorded in SIRS, together with copies of the previous SIC 16, were routinely used as the basis upon which subsequent annual inspections were conducted. However, the continual reliance upon previously recorded data and approvals as a means of quickly assessing the current status of the vessel did not achieve the fundamental intent of the annual inspection, which was to provide an accurate safety audit of the vessel's current condition. This practice led to the repeated acceptance of unsafe features, including non-watertight unsecured hatches and openings in the main deck, inadequate main deck freeing port and drainage arrangements, and insufficient crewing. The conduct of annual inspections of similar vessels in the above manner became the established normal practice of TCMS, and developed into what may be termed a routine annual inspection syndrome in which the previously accepted structural features and information were not questioned or subjected to renewed scrutiny. Consequently, safety audits related to each of the annual inspections of the TRUE NORTH II were based on initially inaccurate assessments of the watertight integrity and the water-freeing capability of the main deck. As a result, the safety audit defences, which should have been integral to each inspection, were lost. The scheduling of inspections of small passenger vessels in the Tobermory area is dictated to a large extent by the seasonal nature of the tourist industry, and most operators seek to have their vessels inspected just prior to the start of each summer season. In practice, to cope with the resultant congestion, several annual inspections were routinely conducted on the same day by whichever TCMS inspector was currently available. The inspectors so employed over the years had knowledge and experience in the various available fields of expertise, including nautical, marine engineering, hull, and small vessels. Since the annual inspections were carried out on the TRUE NORTH II by individual inspectors with specialized knowledge in certain fields and limited cross-training in others, this led to a reluctance to question previously accepted features that were outside an inspector's particular field of expertise. Such inspection procedures contributed to the continued acceptance of shortcomings in the vessel's condition. The perennial continuation of such oversights was the result (in part) of inadequate quality assurance procedures in relation to the administration and monitoring of the annual ship inspection program by TCMS District and Regional offices. 2.7 Passenger Safety Briefings The operator of the TRUE NORTH II did not provide a safety briefing to his passengers. Although such a briefing is not a regulatory requirement, TCMS has issued Ship Safety Bulletin No. 4/95 (SSB) recommending the practice. The passengers were not aware of the location of the lifejackets, or the use of the buoyant apparatus and the liferaft on the vessel. The teachers who had been on the vessel on several previous occasions were unaware of the location of the lifejackets. Once in the water, some of the passengers tried to open the buoyant apparatus believing the lifejackets were inside. In order to prepare for emergency situations, passengers must be well informed of any safety precautions and emergency actions, including the location of emergency equipment available on board. Safety briefings provide critical information to passengers and prepare them for successful evacuation in the event of an emergency. Previous TSB recommendations (M94-04 and M96-05) identified this deficiency, but it continues to be identified in spite of action taken by the authorities. 2.8 Life-saving Equipment It is important that crew members have access to life-saving and emergency equipment to distribute to the passengers to increase their survivability when a vessel is being abandoned. 2.8.1 Carriage and Stowage of Lifejackets The inspection certificates showed that, from 1980 to 2000, the number of adults' lifejackets carried on board the TRUE NORTH II varied between 21 and 25; the number of children's lifejackets varied between 2 and 6. None of the surviving passengers knew where the lifejackets were stowed. Information submitted to TCMS in the spring of 1984 indicates the lifejackets were to be stowed in the benches located on the afterdeck. However, the lifejackets found on the TRUE NORTH II were stowed in a compartment located along the port side passageway directly above the main engine. An opening in the deckhead for the smoke stack and air intake exposed the lifejackets to rain, smoke and ultraviolet light. Rather than modify the compartment, the owner had wrapped the lifejackets in opaque plastic bags to protect them. This practice, routinely accepted by TCMS inspectors who inspected the TRUE NORTH II, made the lifejackets less conspicuous. This situation was not improved by the lifejacket signage. The placement of the sign and the size of the lettering were not sufficient to effectively advise passengers of the location of the lifejackets. In addition, the posting of tourist-related information on the compartment door below the lifejacket sign competed for the viewer's attention. The inadequacy of the signage could have been overcome through a pre-departure safety briefing alerting the passengers to the location of the lifejackets. A lifejacket is designed to provide buoyancy and to keep an unconscious wearer's head face-up above the surface when in the water. For the lifejacket to perform as designed, the size of the lifejacket must be appropriate to the body size of the wearer. If the lifejacket is too big or too small, or is worn incorrectly, the wearer can be at risk of drowning. Current regulations require passenger vessels, similar to the TRUE NORTH II, to carry enough lifejackets for the number of adults authorized to be carried under the inspection certificate issued for the vessel. However, only 10 percent of that number must be lifejackets suitable for children. Only when the vessel regularly carries a known number of children as passengers, is the vessel required to have one lifejacket for each child. In the event of an emergency, it is critical to the safety of all passengers that they each have a suitable lifejacket. 2.8.2 Buoyant Apparatus and Lifebuoys The LSE Regulationspermit a vessel to carry buoyant apparatus instead of a liferaft, provided certain safety requirements are met. In this occurrence, since the vessel sank without the liferaft being deployed, the buoyant apparatus were critical to the master and passengers reaching shore successfully. However, as the buoyant apparatus offered only a small surface area, the master and the passengers were immersed in 10C water. Consequently, they found it difficult to cling to the apparatus and were at severe risk of hypothermia. It should be noted that the vessel sank some 200 m directly upwind of Flowerpot Island, and the waves pushed the apparatus directly towards the island. Because the lifebuoys were stowed inside the viewing well, they were contained within the superstructure and did not float clear of the vessel as she sank. 2.8.3 Inflatable Liferaft Securing and Deployment In 1996 the owner added an inflatable liferaft to the life-saving equipment on board the vessel. The lashing that secured the liferaft in the cradle was fitted with a Senhouse slip that required manual operation in order to deploy the liferaft. The liferaft was not readily accessible, as there was no provision for easy access to the top of the superstructure. Although launching the inflatable liferaft is considered a two-person operation, the vessel was operated single-handedly, and prior to departure the master did not brief any of the passengers to assist him in this task in the event of an emergency. After swimming to the top of the superstructure, the master could not reach the already immersed liferaft in time to manually release the Senhouse slip. As a result, the liferaft sank with the vessel. The liferaft was required to be fitted with either a hydrostatic release unit or to be stowed in deep chocks (without lashings). The absence of either of these devices had not been identified by TCMS inspectors in 1996 when the liferaft was installed, and none was fitted thereafter. As a result, the lashing that secured the liferaft to its cradle was not fitted with a hydrostatic release device or other means to allow the liferaft to float free when the vessel sank. 2.9 Emergency Communications Due to rapidly moving events, the situation became difficult to manage, and after the bridge front door was stove in, the master could not transmit a Mayday or distress signal nor make any request for assistance on the VHF radio. Except for that radio, the vessel had no other means of alerting the CCG station or the parks warden that the vessel was in distress. Like most small passenger vessels, the TRUE NORTH II was not required to carry an automatic distress alerting system such as an EPIRB to alert SAR authorities in the event of a distress situation. At present, passenger vessels under 20 m in length are not required to carry an EPIRB. As there was no sailing plan with a pre-determined time of departure and arrival, no one in Tobermory was aware that the vessel had been lost. Consequently, SAR authorities were not aware of the distress situation until a passing pleasure craft observed the two buoyant apparatus and notified the local Coast Guard radio station. 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors The master sailed to Flowerpot Island in near gale-force winds, while a small craft wind warning and thunderstorm advisory were in effect. On the return voyage, successive waves stove in the vessel's bridge front door and window, and shipped water rapidly flooded the main deck through the front and port side openings of the superstructure. Ineffective scuppers and insufficient freeing port area caused the shipped water to be retained on deck and quickly downflood the underdeck compartment through non-watertight hatches and deck openings. As a result, the vessel lost reserve buoyancy and sank rapidly by the stern. Modifications to the vessel had compromised its watertight integrity. The absence of a pre-departure safety briefing, the inconspicuous lifejacket sign, and the lack of an emergency equipment plan resulted in the passengers being unaware of the location and use of life-saving appliances on board the vessel. At the time of the sinking, the master was in sole charge of the vessel, with no other crew member available to guide or render assistance to the passengers during and after the abandonment. The inflatable liferaft stowed on the top of the superstructure was not readily accessible and required human intervention for its deployment. The liferaft sank with the vessel because it was neither placed in deep chocks without lashings nor fitted with a hydrostatic release unit. 3.2 Findings as to Risk Since 1972, unsafe structural features were improperly assessed during the vessel's annual inspections by TCMS, and remedial action was not taken to address these risks. In the event of underwater damage, the risk of loss of stability and sinking is greatly increased by the absence of transverse watertight bulkheads. The continuous acceptance of structural shortcomings was the result of, in part, inadequate quality assurance procedures in relation to the administration and monitoring of the annual ship inspection program by TCMS. The voyage limitation on the Ship Inspection Certificate restricted the vessel to sail in fine clear weather only at the master's discretion. Such wording is imprecise and does not adequately define wind and sea parameters. The vessel was required to be crewed by two persons, but this requirement was not implemented and subsequent Ship Inspection Certificates made no reference to the requirement for an additional crew member. Due to the rapidity of the sinking, the master did not transmit a distress call on the VHF radio. The vessel was not required to be equipped with an automatic distress alerting system such as an EPIRB, and there was a delay in alerting the SAR station, which increased the on-scene response time. Unsecured debris floating inside the vessel's superstructure may have posed an increased risk to passengers trying to escape the sinking vessel. 3.3 Other Findings The master and 17 passengers, who were not wearing lifejackets, escaped the sinking vessel and swam to two buoyant apparatus which drifted to Flowerpot Island in the onshore wind. TCMS examination and certification procedures did not require examiners to file a report on their assessment of a candidate for oral examination. It is not possible to determine how the examiner assessed the master's competence in operating the TRUE NORTH II. The syllabus for Master, Limited, does not cover ship construction or meteorology, two subject areas that might have helped the master to recognize the vessel's vulnerability. 4.0 Safety Action 4.1 Action Taken 4.1.1 Advisory on Liferaft Release Mechanism In October 2000 and January 2001 the TSB sent a Marine Safety Advisory (MSA 00-09) to Transport Canada indicating serious shortcomings with the inspection of life-saving equipment and the lack of a float-free arrangement for liferafts on many small passenger vessels operating in Canadian waters. In response, TCMS has indicated that an amendment to the LSE Regulations has been prepared and will require vessels under 25 m in length to have liferafts, if fitted, that will float free if the vessel sinks. In the interim, TCMS has drafted a Ship Safety Bulletin to address the stowage and float-free arrangements for liferafts. 4.1.2 Review of Passenger Vessel Inspection and Certification As a result of this occurrence, TCMS initiated a review of its inspection and certification processes and procedures for passenger vessels in the Ontario Region. As a result of this internal review, TCMS made recommendations in four key areas: to review a sample of small passenger vessels' files in different regional offices to detect non-conformities; to institute a formal process of monitoring inspectors' reports on inspections; to avoid the use of fair or fine weather and to define a set of parameters such as sea states; to review regional directives; and to initiate a National Marine Safety Circular from headquarters to the regional offices, and to clients. to update notices to surveyors; to review inputs and extraction of SIRS information and preparation of inspection certificates; to inform inspectors of the required information that is to be placed on a ship file as a result of an inspection; to discuss regulatory and policy changes at regular intervals; to make reference to water temperature in SIRS and on the certificate when the number of persons on board a vessel and the provision of life-saving equipment is based on water temperature; and to provide instructions on the use of special passenger complement allowances shown on the inspection certificates. to develop procedures for provision and distribution of electronic information; to highlight regulatory amendments and changes of policy to marine inspectors; to introduce and ensure availability of a controlled electronic version of all documents; to transmit full text of board decisions; to develop procedures to control the sources of information provided to inspectors; and to provide instruction on the use of forms when new or modified forms are implemented. Training and Performance Assessment of Inspectors to develop procedures to assess marine inspectors' core competencies and regulatory effectiveness; to provide training courses and policies for the proper use of the SIRS II; to locate clients; to institute a training program for new inspectors for early introductory training prior to formal appointments, and to introduce a mentoring program; and to review the appointment of inspectors. Subsequent to the above review, TCMS has advised the TSB of various actions that have been taken, or are planned, to address the four key areas. For details see Appendix C. 4.1.3 Weather Limitation Subsequent to this occurrence, and the above-noted review, TCMS found that the use of fair or fine weather as a voyage limitation is ambiguous and that its use should be discontinued. 4.2 Action Required 4.2.1 Adequacy of TCMS Inspection Regime and Safety Culture Vessels such as TRUE NORTH II are required to be inspected annually to ensure that the structural condition of the hull, the condition of the machinery, electrical, life-saving, navigation and communication equipment continue to be fit for safe operation. The inspection also includes a process to make sure that not only the vessel and its equipment are fit but that crews are competent to safely operate their vessels. The operators of passenger vessels such as TRUE NORTH II, small vessels and small fishing vessels alike, may not always have comprehensive knowledge of safe operating practices and the safety requirements of their vessels. As such, the safety of passengers can become dependent upon safety inspections as a means of ensuring that the condition of these vessels is safe for the intended operation, that adequate safety appliances are carried and that all safety requirements are met. This investigation has found procedural, performance and management deficiencies associated with the safety inspection regime of the safety inspection program. These deficiencies included the following: the inspections did not identify modifications that negatively affected the watertight integrity and overall safety of the vessel; TC Board of Steamship Inspection Meeting (3470) placed a voyage limitation and listed crewing and life-saving requirements for the vessel. These requirements were never transmitted to the vessel's owner; the existing TCMS inspection regime did not ensure that the TC Board of Steamship Inspection decisions were implemented or monitored; the inspections did not identify that the lifejackets and the liferaft were not readily accessible in the event of an emergency; the safety implications of the above shortcomings were not recognized by the inspectors and the annual inspection certificate (SIC 16) was routinely issued; there was no quality control or audit function that might have identified performance deficiencies and non-conformities to alert management to the need for corrective action. The deficiencies in the TCMS ship inspection regime, found in this investigation, are not limited to this vessel, or this region. Since 1990 the TSB has conducted several investigations into marine accidents in which deficiencies related to the ship inspection regime have been noted: For example, in the investigation into the 1998 swamping and sinking of the scallop dragger BRIER MIST (M98L0149), off Rimouski, Quebec, where five fishermen lost their lives, the Board found that despite the vessel having been inspected five times by TCMS inspectors, the hatch covers had not been modified to comply with safety standards. On the basis of the information gathered during the inquest into the BRIER MIST, the coroner also recommended that the existing regulations, with respect to such openings, be enforced by TCMS inspectors. In 1994, following its investigation into the 1990 sinking of the small fishing vessel LE BOUT DE LIGNE (M90L3033) in the Gulf of St. Lawrence, the Board found that there were no procedures in the ship inspection regime for systematically accounting for modifications adversely affecting vessel safety. If TCMS is not notified of such modifications by the owners, inspectors often do not account for the modifications in their routine safety inspections. The Board recommended that TCMS explore means to ensure that added weight and structural modifications are recorded and accounted for in reassessing vessel safety (M94-32, issued December 1994). In response to this recommendation, TCMS indicated that it is the responsibility of the owners/operators to notify it of such modifications and that regulations already exist that require owners/operators to do so. In other words, if the regulations are followed, modifications will be identified and incorporated into the inspection process. This approach to safety does not address this deficiency in the ship inspection regime. Modifications to the TRUE NORTH II, such as the addition of equipment, the welding-shut of the freeing ports and the non-watertight integrity of the deck, went unnoticed and therefore were unaccounted for by inspectors during their routine inspections. As a result of this accident, TCMS, Ontario Region, is conducting its own review of the inspection and certification process in regard to the TRUE NORTH II and similar vessels. The Board understands that the review and audit will not be restricted to this vessel or this region alone and will extend throughout the TCMS organization. The Board is encouraged and hopes that this will lead to the timely identification of safety deficiencies and to effective risk mitigation. The Board also notes that although some actions, recommended by this review may have been completed, many issues have not yet been addressed and several are currently in the planning stage. In view of the fact that quality safety inspections and timely identification of unsafe practices and conditions are critical to the safety of crews and passengers, particularly those carried on small vessels, the Board recommends that: The Department of Transport establish a timetable to expedite the review of the deficiencies in the inspection and certification process, and that it make interim progress reports to the public demonstrating the extent to which these deficiencies have been resolved. M01-01 Furthermore, the Board believes that for the TCMS ship inspection regime to achieve its safety objectives, current systemic deficiencies need to be addressed in a broader context. TCMS bases its safety philosophy on a foundation of compliance with rules. At the same time, however, extensive grandfatheringof vessels takes place, and this permits vessels that have actual or potential safety deficiencies to operate outside appropriate rules. While the Board believes that compliance with rules is necessary, rule compliance alone is not sufficient. A rule-book approach can produce too narrow a focus where safety inspectors routinely do not recognize those safety deficiencies not covered by regulations and, as a consequence, the deficiencies are not addressed. The most rigorous set of rules will not cover every aspect of a safety system. The interpretation and judgement of safety inspectors is necessary to evaluate unsafe conditions both inside and outside the regulatory framework. The Board believes that, with appropriate management support and guidance, TCMS ship inspectors are capable of recognizing and addressing unsafe practices and conditions not proscribed by regulations. Therefore the Board recommends that: The Department of Transport, Marine Safety, instill within its organization an approach to safety that would enable management and safety inspectors to identify and address all unsafe practices and conditions and not limit inspection only to compliance with rules. M01-02 4.2.2 Emergency Preparedness and Survivability In rapidly developing distress situations, such as those encountered by the TRUE NORTH II, it is critical that life-saving equipment be readily available and accessible for use by crews and passengers. Pre-departure safety briefing Previous accidents have convinced the Board that pre-departure safety instructions can increase the chances for survival in an emergency situation. Since there was no life-saving equipment plan or pre-departure safety briefing, the passengers were unprepared for an emergency and did not know the location of the lifejackets or the other emergency equipment and life-saving appliances. The use of this equipment was not demonstrated before departure; such a demonstration is not a common practice among small passenger vessel operations. Such pre-departure safety briefings, and the demonstration of safety equipment, have been the norm on large passenger vessels and in the aviation industry for many years, where they have enhanced passenger safety, and saved lives. In 1996, the Board also recommended to Transport Canada that it require the operators of small sight-seeing boats to provide pre-departure safety instructions to the passengers for normal operating conditions and for emergency situations (M96-05). To date, while operators have been encouraged by Transport Canada to do so, there is no requirement for the operators of small passenger vessels to provide pre-departure safety briefings to passengers. Life-saving equipment It has also been learned that the ready availability of life-saving equipment is crucial to its deployment and use in an emergency situation. Although lifejackets were carried aboard the vessel, they were stowed in such a way that they were not readily available. Two lifebuoys were also carried in such a way that they were not readily available to the passengers in distress. All this life-saving equipment was intended to be used by passengers in an emergency situation, but it was not used. In 1994 the Board issued two recommendations to Transport Canada, that it initiate research and development into ways of ensuring the accessibility of all emergency equipment, including in a capsizing situation (M94-05); and conduct a formal evaluation of current practices for the stowage of life preservers and immersion suits on fishing vessels with a view to ensuring immediate accessibility (M94-08). Action has been taken by Transport Canada in respect of the accessibility of life-saving equipment on board fishing vessels. However, the Board is concerned with current practices on board small passenger vessels which continue to compromise accessibility of all emergency equipment. Liferaft The inflatable liferaft on TRUE NORTH II was not fitted with a hydrostatic release unit, nor was it able to float free; it required human intervention to deploy. In addition, it was secured on top of the superstructure, to which there was no means of easy access. Consequently, it sank with the vessel. After the accident, the TSB conducted an impromptu survey of 25 vessels in the Toronto and Tobermory areas to examine the securing arrangements of liferafts and buoyant apparatus. The survey found that many liferafts on board passenger vessels were installed and secured in such a way that they would not deploy as intended and thus would likely not be of assistance in a distress situation. Subsequently, the TSB apprised TCMS of these unsafe conditions (MSA 09/00). Since 1995, five TSB marine investigation reports found that difficulties were encountered in deploying liferafts due to inappropriate securing arrangements and in which there was a subsequent loss of life.[10] In one instance, involving the sinking of the scallop dragger CAPE ASPY, the Board identified the same deficiency and subsequently TCMS issued a related SSB (No. 9/93) on this subject. Again, as a result of the investigation into the sinking of BRIER MIST, the TSB forwarded another MSA (No. 09/00) to TCMS on the same subject. The Board notes that, as a result of the MSA 09/00, TCMS is preparing an amendment to the LSE Regulations that will require all vessels under 25 m in length to have liferafts arranged for float-free operation. However, these requirements will not apply to fishing vessels and vessels under 5 tons which carry fewer than 12 passengers. The deficiency will continue to exist on fishing vessels, which account for approximately 50 per cent of all accidents. Emergency communications It is essential that shore-based facilities be able to respond to emergency situations without delay. Time gained in the initial stages of an occurrence can be crucial to the saving of life. In this instance, the rapidity with which the TRUE NORTH II sank precluded a Mayday transmission. The rescue effort began once search and rescue authorities were informed of the accident by a vessel which happened to pass by and noticed the people in the water. There are a number of means, available on the market, of alerting others of an emergency situation, other than calling on a marine VHF radiotelephone. These include emergency position-indicating radio beacons (EPIRBs) and search and rescue transponders (SARTs). In 1994, as a result of the accident involving a small open charter boat (M92W1031), the Board issued a recommendation that Transport Canada encourage all charter vessel operators to equip their vessels with life-saving and emergency communication and/or signalling equipment suitable for the type of operation (M94-03). While EPIRBs and SARTs are required to be carried on vessels, they are not required on small vessels such as the TRUE NORTH II in her area of operation. Despite identification of these safety deficiencies relating to emergency preparedness and survivability, the Board's recommendations and Transport Canada's subsequent action taken, the Board's investigations continue to demonstrate that these safety deficiencies remain unresolved. The Board therefore recommends that: The Department of Transport require small passenger vessels to provide pre-departure briefings, and to be equipped with a liferaft that is readily deployable, life-saving equipment that is easily accessible, and the means to immediately alert others of an emergency situation. M01-03 Assessment/Reassessment Rating:Satisfactory Intent 4.3 Safety Concern 4.3.1 Crew Competency Evaluation and Certification Process TCMS issued the operator of the TRUE NORTH II a CSC certificate in 1980 after an oral examination. As a result of a regulatory change, the certification was exchanged for a CL certificate in 1997, without examination. The CL certificate is a certificate of competency that has to be renewed every five years. The certificate requires oral, written and practical examination on subject matter appropriate to the area of operation and the type of vessel to which the certificate applies. However, TCMS examiners may renew certificates, without an examination, if they are satisfied that holders have continued to and will operate in the same certificated capacity. In a previous occurrence, involving the tanker PETROLAB (M97N0099), TCMS was apprised of a similar safety issue: the issuance of a tanker endorsement based upon previous experience, without an examination. The assessment of the competence of the operator of the TRUE NORTH II was based on his possession of an existing certificate and on his experience working in the Tobermory area for a long time. However, throughout this time he had operated his vessel with a number of unrecognized unsafe conditions and practices that compromised safety. The investigation found that the following unsafe conditions and practices had become the norm over a period of several years: the lifebuoys and the liferaft were stowed or fitted in a manner that made them not readily available for deployment, and they sank with the vessel; the lifejackets were wrapped in plastic bags and were stowed in a compartment that was neither easily accessible nor readily identifiable; two freeing ports had been welded shut, which prevented water shipped on deck from draining overboard; the vessel was operated without a means of closing the openings in the main deck; the vessel was operated with insufficient freeing-port area, such that shipped water was entrapped, to the detriment of vessel freeboard and stability; and, a ventilation opening in the engine-room casing compromised the watertight integrity of the hull. Individually, these deficiencies might not have resulted in the sinking of the vessel and the loss of life, but together they did. For an operator to take the measures necessary to minimize risk, the operator must be aware of safety deficiencies. This awareness depends on an operator having sufficient knowledge to understand how the deficiencies present a risk to safety. The master of TRUE NORTH II was initially examined, and his certificate renewed, several times by TCMS. Given the above unsafe conditions and practices, the basis on which the certificate was granted and renewed is questionable. However, since documentation of the evaluation process for the issuance of the certificates was not kept, the Board was unable to identify specific shortcomings in the process. In the past decade, the TSB has identified deficiencies in training, knowledge and certification requirements for operators in several of its investigations into accidents involving small passenger vessels, work boats, and small fishing vessels. In its report on the swamping of the CROWN FOREST 72-68 (TSB Report No. M93W0005), the Board noted that trained personnel with a knowledge of the vessel's stability and of free-surface effect would have been able to recognize the risks associated with operating the craft under the conditions that led to the sinking of the vessel. In its report on the capsizing of the fishing vessel FLYING FISHER, the Board expressed concern that inadequately trained personnel on fishing vessels were contributing to the frequency and the severity of such marine occurrences (TSB Report No. M91W1075). As a result of the investigation into the accident involving the small sight-seeing vessel TAN 1 (TSB Report No. M93L0003), the Board noted that the lack of adequate knowledge of safety measures can have serious consequences in emergency situations. Consequently, the Board recommended that: The Department of Transport develop training standards and certification requirements for the operators of small sight-seeing boats that carry fare-paying passengers. (M96-01, issued March 1996) The aforementioned findings and recommendations underline the critical importance of the knowledge, skill, and competency of masters and officers to the safety of persons on board. TCMS's initial certification and renewal process is to confirm that operators possess__and continue to possess__the knowledge and competence necessary for the safe operation of the vessel and for the safety of the people it carries. The Board is concerned that any shortcoming in the evaluation and certification process may result in allowing operators with inadequate competency to maintain and operate vessels, thereby inadvertently placing crews and passengers at undue risk in emergency situations. The Board will be monitoring the situation to determine if appropriate remedial action is being taken and will assess the need for further action on this issue.